| NPI | 1336110600 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 59459) |
| Additional Taxonomies | 208D00000X General Practice (Licence: ND 10065) |
| Enumeration Date | 2006-01-27 |
| Last Update Date | 2021-06-10 |